Dr.sundeep Jeten Raj

8/3/2019 Dr.sundeep Jeten Raj

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EVALUATION OF RESULTS OF

SUPRACONDYLAR DOME

OSTEOTOMY IN

CUBITUS VARUS DEFORMITY

A DISSERTATION SUBMITTED TO

UNIVERSITY OF SEYCHELLES

AMERICAN INSTITUTE OF MEDICINE

IN PARTIAL FULFILLMENT OF THE REGULATIONS FORTHE

AWARD OF

M.CH. ORTHOPAEDICS

APRIL 2011

BY

DR.SUNDEEP JETEN RAJ


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CONTENTS

Introduction....01Aims and Objectives..02Materials and Methods...03Results and Analysis .13Discussion ..15Conclusion ......18Clinical Photographs ......19References ......21


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INTRODUCTION


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INTRODUCTION

Cubitus varus (gunstock deformity) is the most common long term complication of childhood

supracondylar fracture of the humerus, irrespective of the method of treatment.Cubitus varus

deformity following supracondylar fracture of the humerus in children consist of varus,

hyperextension and internal rotation of the distal bone fragment of the humerus. The usual

presenting complaint is deformity not functional disability. As the deformity is unsightly, the

childs parents often request for an operation to improve the appearance of the elbow ;

although the function is not greatly impaired. Because cubitus varus deformity persists and

has no spontaneous remolding, so the only method to correct the deformity is surgery.

Various corrective osteotomy procedures have been proposed for treatment of cubitus varus .

The goals of osteotomy are correction of the coronal, sagittal and rotational deformity.

Prevention of elbow stiffness, through firm fixation of the osteotomy site and early use of the

joint, is also desirable. The lateral closing wedge osteotomy is the most widely used method

to correct this deformity, but the clinical results have been disappointing.The closing wedge

osteotomy, although deceptively simple ,has a significant complication rate .In the study of

Oppenheim et al , with an average follow up of 21/2years ,24% of patients had complications

of neurapraxia, sepsis or cosmetically unacceptable scarring. In the study of Ippolito et al

with an average of 23 years, all but two of the 19 patients in whom the carrying angle had

been measured preoperatively lost correction that had been obtained during surgery. If the

distal humeral physis is not affected and the distal end of the distal humerus grows uniformly,

the deformity can be corrected permanently. When direct physeal injury has occurred, the

possibility of late recurrence of the deformity after the corrective osteotomy always should be

considered. Although the lateral closing wedge osteotomy is the simplest method of

correction, it has many technical pitfalls, and its tendency to produce a prominent lateral

condyle after the angulations is corrected often compromises the cosmetic outcome.In 1972, a dome osteotomy was initially mentioned by Tachdjian without giving details

to overcome several reported complications of lateral closing-wedge osteotomy.Then Higaki

and Ikuta (1982) reported the same kind of osteotomy in Japanese.

After that several authors

have reported the usefulness of dome osteotomy for cubitus varus deformity.

Traditionally many surgeons believed that the lateral closing wedge osteotomy is the best

treatment for correction of cubitus varus deformity. There have been a number of studies in

the west in recent times which highlight the advantages of dome osteotomy for correction of

cubitus varus deformity.


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AIMS

AND

OBJECTIVES


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AIMS & OBJECTIVES

The aim of our study was to evaluate the results of dome osteotomy in respect of pre and

post-operative carrying angle, range of motion and lateral condylar prominence index to

avoid cosmetic complication and achieve a better functional outcome.

The main objectives were:

1. To study the anatomical deformity before and after theoperation.

2. To study the cosmetic deformity before and after the operation.3. To study any association between the different variable like carrying angle,

lateral condylar prominence index before and after the dome osteotomy.


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MATERIALS

ANDMETHODS


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MATERIALS AND METHODS

The study was conducted in the department of Orthopaedics, Medical College and Hospital,

Kolkata on a prospective basis from March 2009 to April 2010. We selected 12 patients who

fitted our criteria for the study. A written consent was obtained from all the patients.

Study Place: Department of Orthopedics ,Calcutta Medical College, Kolkata.

Study period: March 2009 to April 2010

12 patients of cubitus varus deformity were selected for dome osteotomy. There were some

inclusion and exclusion criteria.

Inclusion criteria:

1. Age of patient 5 to 15 years.2. Appearance of deformity more than 12 months.

Exclusion criteria:

1. Patient younger than 5 and older than 15 years.2. Occurrence of deformity less than 12 months.3. Anesthetically unfit patient.4. Associated with other serious injuries or co-morbid medical illness.

PREOPERATIVE ASSESSMENT

Anteroposterior (elbow in full extension and forearm in full supination) and lateral

radiographs of both elbows were taken. The humerus-elbow-wrist angle was measured on

both sides in all patients using the Oppenhiem method and the angle of correction was

estimated (Fig 1). The lateral condylar prominence index (LPI) was calculated on the affected

side as described by H.K.Wong (Fig2). Range of motion of the affected elbow was noted,

along with complaints of cosmesis, pain and loss of motor power.


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Fig 1 Fig2

Fig.1: Estimation of angular correction using the method of Oppnheim.

Fig.2: The lateral condylar prominence index (LCPI)=(AC-BC) x 100/AB. There is

usually a slight medial prominence, making the LCPI predominantly negative.

PREOPERATIVE PLAN FOR OSTEOTOMY

First the humerus-elbow-wrist angle of both sides were measured. Then angle of correction

was calculated. The mid humeral axis of the affected side was then drawn over the

anteroposterior radiograph of the affected side. A point (point O) was marked where this axis

cut the olecranon fossa, another point (point A) was marked at the junction of lateral condylar

epiphysis with distal humerus. Then point O and point A were joined. Then the angle of

correction making OA as base was drawn. Another point was drawn were this angle cut the

distal humerus (point B). Now O became the center of the dome and OB the radius of the

dome. With this radius a dome was drawn making point O as the center(Fig 3).The arc of the

dome was the proposed site of osteotomy.

Fig 3

Fig 3:Dome supracondylar osteotomy.The intersection

of the midhumeral axis and the upper border of the

olecranon fossa were designated as the center of thedome (point O).The junction of lateral condylar

epiphysis with distal humerus marks another point A.

With the segment of OA as the base a second line, OB,

was drawn according to the planned angle of correction

(). Point B acted as the starting point of the osteotomy

and a dome was drawn with OB as the radius of the arc.


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INDICATIONS OF SURGERY

The indication for surgery in all these cases was the unacceptable appearance of the elbow.

SURGICAL TECHNIQUE

All operations were done under general anesthesia.

The patients were placed in a lateral position and a tourniquet was applied. The affected arm

was placed on a support allowing at least 90 of elbow flexion.

Fig 2: Position of Patient during

Operation.

Fig 1:- General Anesthesia is given


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A midline posterior incision was performed, curving laterally around the olecranon. It was

continued about 3 cm distal to the olecranon tip.

The fascia overlying the triceps brachii was identified, split in the midline, and elevated with

the dermis and subcutaneous tissue, creating two fasciocutaneous flaps. Dissection was

continued to the lateral and medial triceps borders at their respective interfaces with the

posterior aspects of the intermuscular septae. In this way, the triceps muscle was separated

from the posterior surface of the intermuscular septae. The posterolateral humeral shaft was

approached by elevating the triceps muscle from the posterior periosteum and by retracting it

medially.

Fig 3: Posterior Midline Longitudinal

skin Incision.

Fig.4: Triceps muscle elevated from

postero-lateral surface of the humerus


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Medially, the ulnar nerve was identified and exposed proximally in the posterior

compartment. In order to avoid injury to the ulnar nerve, it was protected with a penrose drain

during the operation.

Medial paratricipital dissection along the posterior border of the intermuscular septum

exposed the posteromedial aspect of the distal humerus.

Fig.5: Dissection of ulnar nerve

and protected with penrose drain

Fig 6: Medial paratricipital

dissection and exposure of postero-

medial aspect of distal humerus


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During the osteotomy retractors were placed along the anterior cortex to protect the

neurovascular bundles in the anterior cubital fossa. Interrupted holes were made along the

presumed osteotomy arc by 1.8 mm k- wire drilling through the anterior and posterior

cortices of the humerus

The osteotomy was completed with a inch osteotome.

Fig 9: Marking of osteotomy site

Fig 11: Osteotomy done by

osteotome


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After the osteotomy was completed, the proximal fragment had to be pulled outwards by a

bone hook to facilitate complete division of the thick anterior periosteum and to smooth the

spikes over the edge of the anterior cortex on the proximal and distal fragments.

The AB segment of the lateral cortex was curved to fit the arc of the dome shaped osteotomy.

Then the distal fragment could be rotated along the arc until point A on the distal fragment

and point B on the proximal fragment overlapped .Thus the elbow was realigned as planned.

Fig 12: Smoothening the spikes over

the edge of proximal fragment

Fig 13: Planning of fixation ofosteotomy site


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Percutaneous cross k-wire (1.8mm) fixation for the osteotomy was done.

The Kirshner wires were bent and kept proud to facilitate easy removal later. The wound was

closed in layers and no drain was given in routine cases.

Postoperatively, patient was asked to do pendulum movements of the shoulder and active

exercises of the fingers and wrist started immediately. Stitches removed 14 days postop.

Back slab was removed after four weeks and the K wires removed after fifth week. Gentle

active movements of the elbow was encouraged. Radiographs were obtained in

anteroposterior and lateral projections every month for the first three months and then every

three months till final follow up.

Fig 14: Fixation of osteotomy site

with crossed k-wire


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FOLLOW-UP ASSESSMENTS

Follow up of the patients ranged from 5 months to 12 months. All patients and their parents

responded to a questionnaire similar to that used by Barrette al to measure consumer

satisfaction with the cosmetic outcome. The questions were as follows:

1. Does your childs arm look crooked?2. Do you or your child notice a bump?3. Does the bump bother you or your child?4. Do you or your child notice the operation scar?5. Does the scar bother you or your child?6. Are you and your child pleased with the result?7. Would you repeat the operation if given the same circumstances?

Clinical assessment included the subjective evaluation of the lateral condylar prominence,

cosmesis and scar. The range of motion complications were also noted. Radiograpic

assessment included the measurment of the carrying angle and LCPI as said before.

Postoperative change of the lateral condylar prominence had a cosmetic significance. The

operative time, blood loss, neurological complications, wound healing and pin tract conditionwere all recorded. Carrying angle, ROM and change of lateral condylar prominence index

were used as strict criteria to categorize the results. The results of the osteotomy were

categorized as excellent, good and poor as in Table I.

Table I: Showing Gradation Of Results

CRITERIA EXCELLENT GOOD POOR

Carrying angle Difference in the anglefrom the unaffected side

was 5* or less

Difference in the anglefrom the unaffected side

was 6* to 10*

Difference in the anglefrom the unaffected side

was more than 10*

Range of motion Loss of flexion &

extension was 10* or less

Loss of flexion &

extension was 20* or less

Loss of flexion &

extension was more than

20*

Lateral condylar

prominence index

No increase in the lateral

condylar index

Increase in the lateral

condylar index was 2.5%

or less

Increase in the lateral

condylar index was more

than 2.5%


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RESULTS

AND

ANALYSIS


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RESULTS AND ANALYSIS

All twelve patients were reviewed clinically and radiographically. Follow up ranged from 5

to 12 months. Seven patients had an excellent result, four had good and one had poor (Table

II).

FLEXION

Before operation, the range of motion was normal in seven patients and five had

hyperextension (10 degrees in two 5 degrees in three). The average range of motion was

127.9 degrees before surgery and 123.3 degrees after surgery.

COSMETIC OUTCOME

In terms of appearance of elbow only one patient reported an unsightly scar. None of the

patients had a prominent lateral condyle and there was no complaint of medial fullness of

elbow.

COMPLICATION (Table II)

This include superficial skin infection and ulnar neuropraxia in one patient each. Ulnar nerve

neuropraxia manifested in the form of tingling and numbness in the ulnar distribution without

any motor weakness and resolved spontaneously. Superficial skin infection was treated with

oral antibiotics and dressing but left sequel of ugly scar. No patient reported pain, motor

weakness or atrophy of the arm musculature. There was no fixation failure or loss of

correction during healing stage and no revision surgery was needed.

RADIOGRAPHIC ASSESSMENT (Vide Table II)

The pre-operative humerus elbow wrist angle was average -16.8 degrees (range -2 to -30

degrees). The post operative angle was 12.4 degrees valgus (range 4 to25 degrees valgus). In

seven patients the carrying angle was within 5 degrees of the contralateral unaffected side.

The pre-operative LCPI varied from -45.95 to 15.56. The post operative LCPI varied from -

40.54 to 26.08. Compared with the preoperative values, the LCPI actually decreased after the

surgery.


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DISCUSSION


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DISCUSSION

Cubitus varus is one of the most common complications of supracondylar fractures of the

humerus in children treated with nonoperative management without reduction and fixation.

Its reported incidence varies from 4% to 58%. It may result from inadequate reduction, fromloss of reduction with consequent malunion or from disturbance of growth at the lower end of

the humerus. Most authors consider the deformity to result from inadequate reduction that

leaves a residual rotatory deformity that can collapse into medial tilt and therefore results in a

varus deformity. In my series, all 12 patient had previous history of supracondylar fracture of

humerus and all these fractures were treated conservatively .There was no history of any

other associated injury.

Although cubitus varus has recently been reported to be associated with ulnar neuropathy,

snapping of the medial portion of the triceps,secondary distal humeral or lateral condylar

fracture, avascular necrosis of the distal humeral epiphysis, and tardy postero lateral rotatory

instability of the elbow, in most of the patients the usual presenting complain is an unsightly

deformity rather than a functional disability. In my study , the indication for surgery in all 12

patients was an unsightly deformity .All of the patients have normal elbow function .

Various corrective procedures for cubitus varus deformity have been described. These

include medial opening wedge osteotomy, lateral closing wedge osteotomy, lateral closing

wedge osteotomy with simultaneous derotation arc osteotomy, pentalateral osteotomy and

dome osteotomy . The lateral closing wedge osteotomy is the most commonly used procedure

to correct the deformity. However, in osteotomies that do not allow translation of the distal

humerus, the appearance of the joint after surgery is different from that of the unaffected side,

as if the varus deformity still exists, although the carrying angle of the affected elbow is

corrected to match the angle of the unaffected side. Thus, it was said that this residual

cosmetic appearance might be due to a radial shift in the distal fragment of the humerus,

relative to the proximal humeral shaft, causing a protrusion of the lateral humeral

condyle.Wong et al reported an incidence of 64% of this complication in a series of 22

patients. The cause of this prominence of the lateral condyle is inherent in the design of the

lateral closing wedge osteotomy. Excision of the wedge leaves two fragments of unequal

width and hinging on the medial cortex, whereas closing the osteotomy effectively shifts the

distal fragment laterally, thus making the lateral condyle more prominent and compromising

the cosmetic out come.


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Tachdjian, who did not report any results, first describe the dome osteotomy for correction

of cubitus varus. Good results with out complications were reported by Kanaujia et al19

and

Tien et al. In my series, except one none of the other patients had lateral condylar prominence

after correction of the deformity be the technique of dome osteotomy. The lateral condylar

prominence index improved in 11 out of 12 patient. Dome osteotomy uses the midline of the

humerus as the centre of rotation, therefore, the lateral condyle dose not shift with reference

to the midline and the lateral condyle is thus prevented from becoming prominent.

Apart from the tendency to produce lateral condylar prominence, lateral closing wedge-

osteotomy has another pitfall. The center of rotation of the distal humeral fragment is located

at the medial cortex, making a large rotation arc necessary for the distal fragment to be

mobilized during correction of the deformity. This result in the further tightening of the

already contracted medial structures and a large varus moment acting on the osteotomy site

.In this situation, the osteotomy is mechanically unstable, and loss of correction would occur

easily if the fixation were inadequate. On the , other hand ,in dome osteotomy ,because the

centre of rotation of the distal fragment is at the midline of the humerus ,the varus moment

acting at the osteotomy site is much less ,making the osteotomy mechanically more stable.

Ippolito et al 21 reported approximately 60% of the patient reported an unattractive

postoperative scar. In my study, one patients reported an unattractive scar because of

superficial skin infection. None of my patient had any history of pin tract infection, pin

loosening, and elbow stiffness. I used a posterior longitudinal incision to approach the lower

end of the humerus. Scar is cosmetically more acceptable after dome osteotomy. The locationof the scar is posterior when the arm is hanging down at rest and down when the pronated

Lateral closing-wedge osteotomy results

in two fragments of unequal widths and

the lateral cond le becomes rominent

In contrast, no such lateral condylar

prominence occurs after dome

osteotomy


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forearm is resting on a desk, making the scar more less obvious.The standard lateral

longitudinal incision used for the lateral closing wedge osteotomy directly crosses the

Langers lines in that area, leading to a tendency towards hypertrophic scar.

The results of the dome osteotomy for the correction of cubitus varus deformity in my series

were comparable to dome osteotomy by various authors in terms of the correction of carrying

angle, overall results and the incidence of complications (infection, neurapraxia, loss of

correction) .


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CONCLUSION


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CONCLUSION

Twelve patients between 5-15 years of age were selected with cubitus varus deformity all of

whom presented after 12 months of appearance of the deformity. Seven of the patients were

males and the rest were females. The entire patient had previous history of supracondylarfracture.

Pre-operatively carrying angle, lateral condylar prominent index, range of motion were

recorded.

The patients were treated with dome osteotomy.A posterior longitudinal midline incision was

used for the osteotomy. After osteotomy, fixation of the osteotomy site was done by giving

cross K- wires.

There were no intraoperative complications.

Postoperatively, one patient developed superficial skin infection. Other complications in

our study were one patient had ulnar nerve neurapraxia; one patient had cosmetically

unacceptable scar. But no elbow stiffness, pin tract infection, nonunion of osteotomy site was

there.

Active range of motion exercises of the elbow were started 5 weeks after the operation .The

cases were followed up on a weekly basis till the removal of the k- wire. Then it was

fortnightly basis till acceptable uncomplicated range of motion was regained and monthly

thereafter.

The results were graded according to the pre-operative and postoperative carrying angle,

movement of flexion and extension, lateral condylar prominence index and they were

statistically evaluated.

Pre-operative and post-operative extension, carrying angle and lateral condylar prominence

index has got statistical significance.

I conclude that dome osteotomy for the correction of the cubitus varus deformity is associated

with an excellent cosmetic outcome and low complication rates. Dome osteotomy was found

to have the following advantages for correction of cubitus varus deformity: the osteotomy site

is more stable than a lateral closing wedge osteotomy for maintaining the correction, it avoids

the lateral condyle becoming prominent and the posterior scar is more cosmetically

acceptable than the lateral scar in the lateral closing wedge osteotomy. Dome osteotomy is a

simple, safe and technically sound procedure that prevents the lateral condyle from becoming

prominent and yields a near-normal cosmetic outcome.


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CLINICAL

PHOTOGRAPHS


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CLINICAL PHOTOGRAPHS

Immediate post-

operative radiograph AP

View

Immediate post-

operative radiograph

Lateral view

Pre-operative Lat

View of affected side

Pre-operative AP View

of affected side

Pre Operative photograph of Mithun Talukdar ,7yrs old boy.


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Follow-up after

12 months

Follow-up after 12

months showing

extension

Followup 12

months showing

flexion

Post-operative follow-

up after 12 months AP

View

Pot-operative follow-up

after 12 months LateralView


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REFERENCES


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REFERENCES

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2. Piggot J, Graham MK, Mc Coy GF. Supracondylar fracture of the humerus inchildren: treatment by straight lateral traction. J Bone Joint Surg [Br]. 1986; 68:577-

583.

3. Oppenheim WL, Clader TJ, Smith C, et al. Supracondylar humeral osteotomy fortraumatic childhood cubitus varus deformity. Clin Orthop.1984; 188:34-39.

4. Ippolito E, Moneta MR, DArrgio C: Post-traumatic cubitus varus . Longtermfollow- up of corrective supracondylar humeral osteotomy in children. J Bone JointSurg [Am] .1990; 72A:757-765.

5. LaBelle H , Bunnell WP, Duhaime M , et al . Cubitus varus deformity followingsupracondylar osteotomy of the humerus in children. J Paediatr Orthop . 1982;

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6. Griffin PP. Supracondylar fractures of the humerus. Pediatr Clin North Am.1975; 2:477-486.

7. Wong HK, Lee EH, Balasubhramaniam P. The lateral condylar prominence. Acomplication of supracondylar osteotomy for cubitus varus. J Bone Joint Surg

[Br].1990; 72:859-861.

8. Barrett IR, Bellemore MC ,Kwon YM. Cosmetic results of supracondylar osteotomyfor correction of cubitus varus. J Pediatr Orthop. 1998; 18:445-447.

9. King D, Secor C. Bow elbow (cubitus varus).J Bone Joint Surg [Am] .1951; 33:572-576.

10.Carlson CS, Rosman MA. Cubitus varus: a new and simple technique of correction. JPediatr Orthop .1982; 2:199-201.

11.Graham B. Supracondylar osteotomy of the humerus for correction of cubitusvarus. J Pediatr Orthop .1990; 10:228-231.

12.Mahaisavariya B, Laupattarakasem W. Osteotomy for cubitus varus : a simpletechnique in 10 children .Acta Orthop Scand. 1996; 67:60- 62.

13.Matsushita T , Nagano A. Arc osteotomy of the humerus to correct cubitus varus. ClinOrthop .1997; 336:111-115.

14.Kanaujia RR, Ikuta Y, Muneshige H, et al. Dome osteotomy for cubitus varus inchildren. Acta Orthop Scand.1988; 59:314-318.


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15.Tachdjian MR. Osteotomy of distal humerus for correction of cubitus varus. In:Smith AB , ed. Pediatric Orthopedics. Philadelphia: WB Saunders; 1972:1588-1591.

16. Tien YC, Chih HW, Lin GT, et al. Dome corrective osteotomy for cubitus varusdeformity. Clin Orthop. 2000; 380:158-166.

17.Laupattarakasem W, Mahaisavariya B, Kowsuwon W, et al. Pentalateral osteotomyfor cubitus varus : clinical experience of a new technique. J Bone Joint Surg [Br].

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18.Bellemore MC, Barrett IR, Middleton RWD, et al. Supracondylar osteotomy of thehumerus with correction of cubitus varus. J Bone Joint Surg [Br].1984; 66:566-572.

19.Wilkins KE: Fractures and Dislocations of the Elbow Region. In Rockwood CA,Wilkins KE. King RE(eds). Fractures in children. Ed 4. Philadelphia, JB Lippincott

Company 604-605, 1990.20.Higaki T, Ikuta Y. The new operation method of the domed osteotomy for 4 children

with varus deformity of the elbow joint. J Jpn Ortho 1982; 31:300-35.

21.Pankaj A, Dua A, Malhotra R, Bhan S. Dome osteotomy for posttraumaticcubitus varus: a surgical technique to avoid lateral condylar prominence. J Pediatr

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http://www.ncbi.nlm.nih.gov/pubmed/16439904?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/pubmed/16439904?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/pubmed/16439904?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/pubmed/16439904?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

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Dr.sundeep Jeten Raj